Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke - EXTEND-IA TNK

Contribution To Literature:

The EXTEND-IA TNK trial showed that tenecteplase was superior to alteplase at improving reperfusion and functional outcomes.


The goal of the trial was to evaluate intravenous tenecteplase compared with alteplase before endovascular thrombectomy for ischemic stroke.

Study Design

  • Randomized
  • Parallel
  • Stratified

Patients within 4.5 hours from symptom onset of ischemic stroke and undergoing endovascular therapy were randomized to tenecteplase 0.25 mg/kg (n = 101) versus alteplase 0.9 mg/kg (n = 101).

  • Total number of enrollees: 202
  • Duration of follow-up: median 90 days
  • Mean patient age: 70 years
  • Percentage female: 33%

Inclusion criteria:

  • Ischemic stroke due to occlusion of the internal carotid, basilar, or middle cerebral artery
  • Within 4.5 hours of symptom onset

Exclusion criteria:

  • Pre-existing disability

Principal Findings:

The primary outcome, reperfusion of >50% of the involved ischemic territory or an absence of retrievable thrombus at the time of the initial angiographic assessment, occurred in 22% of the tenecteplase group compared with 10% of the alteplase group (p for noninferiority = 0.002, p for superiority = 0.03).

Secondary outcomes:

  • Symptomatic intracerebral hemorrhage: 1% in the tenecteplase group vs. 1% in the alteplase group
  • Death: 10% in the tenecteplase group vs. 18% in the alteplase group (p = 0.049)


Among patients with acute ischemic stroke undergoing endovascular therapy, tenecteplase was associated with a higher incidence of reperfusion and better functional outcome compared with alteplase. Intracranial hemorrhage was similar between groups. The bolus infusion of tenecteplase is practically easier to administer than a 1-hour infusion of alteplase.


Campbell BC, Mitchell PJ, Churilov L, et al. Tenecteplase Versus Alteplase Before Thrombectomy for Ischemic Stroke. N Engl J Med 2018;378:1573-82.

Editorial: Paving the Way for Improved Treatment of Acute Stroke with Tenecteplase. N Engl J Med 2018;378:1635-6.

Clinical Topics: Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Lipid Metabolism, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Angiography, Brain Ischemia, Cerebral Hemorrhage, Endovascular Procedures, Intracranial Hemorrhages, Secondary Prevention, Reperfusion, Stroke, Thrombectomy, Thrombosis, Tissue Plasminogen Activator

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